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   Table of Contents - Current issue
Coverpage
May-August 2020
Volume 9 | Issue 2
Page Nos. 77-175

Online since Tuesday, August 25, 2020

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ORIGINAL ARTICLES  

Student-generated formative assessment and its impact on final assessment in a problem-based learning curriculum p. 77
Mazhar Mushtaq, Muhammad Abdul Mateen, Khawaja Husnain Haider
DOI:10.4103/sjhs.sjhs_98_20  
Objective: Besides modified essay questions (MEQs), well-structured multiple-choice questions (MCQs) are one of the most well-established tools for both summative and formative assessment strategies due to their applicability and objectivity. Nevertheless, the construction of high-quality MCQs is a time-intensive exercise for the medical faculty. As our curriculum in medicine is based on problem-based learning (PBL) approach wherein students are central to the process of teaching and learning, we aimed to study the beneficial effects of students' involvement in MCQ writing on their learning process. We hypothesized that the involvement of students in MCQ writing would be a motivational exercise for their improved learning. Methods: A retrospective study was designed in the medical school to analyze end-of-the-block examination feedback data from students (n = 287), spanning over three academic sessions for Block 1.4 entitled “Thinking and Doing”. The proposed activity was carried out with or without the involvement of students in MCQ writing and it formed a part of their formative assessment during the block. Results: Analysis of the students' feedback conducted by the Planning, Development, and Quality Assurance survey using Qualtrics at the end of the course, supported by the Google survey conducted by the block coordinator, showed that student performance was significantly improved when they were involved in an incentive-driven MCQ writing exercise for formative assessment and an in-depth discussion at the end of each tutorial session of their PBL curriculum during the block.Conclusions: Our data strongly support our hypothesis that the formative assessment of MCQs written by the students enhances their learning in the PBL-based curriculum.
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Relationship of text length of multiple-choice questions on item psychometric properties – A retrospective study p. 84
Dareen Khalid Aljehani, Fawaz Pullishery, Omer Abdelgadir Elfaki Osman, Basem Mohamed Abuzenada
DOI:10.4103/sjhs.sjhs_76_20  
Background: Item writing flaws while constructing multiple-choice questions (MCQs) have serious impact on different psychometric properties of questionnaire. The study aimed to evaluate the relationship of length of questions of (MCQs) items on difficulty factor (DF), discrimination index (DI), and Point Bi-serial (rBP) of a dental program assessment. Materials and Methods: The cross-sectional study included 627 MCQs. The data were analyzed from the report achieved through ExamSoft software. The questions were divided into long (words >100); medium (words of 70–100); and short (words <70). We divided the DF into hard (DF <0.3), average (DF = 0.3–0.8) easy (DF >0.8); DI into negative (DI <0), DI = 0–0.2 and DI >0.2; Point Bi-serial into “Negative” (rBP <0), rBP = 0–0.2 and rBP >0.2; Pearson's Chi-square test was used to find a relationship between length of question with other variables. Results: Thirty-one long MCQs, 56 medium, and 540 short MCQs were achieved based on the analysis. There was a statistically significant association found between DF and length of the questions (P < 0.05). No significant relationship between the length of the questions with DI and Point Bi-Serial factors. The median of DF was 0.6300 (interquartile range [IQR] 0.41). The median length of the MCQs was found to be 35.0 (IQR 25.0). Conclusion: The study proved that the length of the question has an impact on the DF but not always with the DI or Point Bi-serial.
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Verification and validation measures of hearing aid outcome: Audiologists' practice in Saudi Arabia p. 88
Ahmad A Alanazi
DOI:10.4103/sjhs.sjhs_27_20  
Background: The best practice guidelines require verification and validation measurements for fitting hearing-impaired patients with hearing aids (HAs). The clinical practice for verifying and validating HAs fitting in Saudi Arabia (SA) is unknown. Objectives: This study aimed to examine how audiologists verify and validate HAs fitting in SA. Materials and Methods: A convenience cross-sectional descriptive study design was used to address the aim of the study. An online-validated questionnaire was prepared and electronically distributed to reach a large number of practicing audiologists in SA. The questionnaire consisted of 16 close-ended questions and primarily focused on two categories demographic information and HAs fitting. Results: A total of 80 audiologists completed the questionnaire. The majority of participants were female (66.3%), from the central region (71.2%), worked in governmental hospitals (65%) with both adult and pediatric patients, and had different academic qualifications and teaching experiences. Audiologists (98.2%) mainly relied on the patient's feedback and the functional gain to verify HAs fitting. More than half of the participants either never or rarely used real ear measurements and coupler-based measurements. Unstructured general questions were mostly used by 65.5% of audiologists to validate fittings. The lack of equipment, time, and proper training were the core reasons for not following the best practice approach for fitting HAs. Conclusions: Verification and validation provide audiologists with confidence that their patients satisfy with HAs. Employers need to equip audiology clinics with HAs verification systems, allow more time-slots for HAs fitting cases and support up-to-date training for audiologists. To encourage validating HAs fitting regularly, audiologists are advised either to utilize already existed Arabic validation tools or to translate and validate other tools in English.
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A survey on the knowledge and attitude on pain management among nurses employed in the government hospitals p. 97
Andres S Panlican, Eddieson A Pasay-an, Ferdinand M Gonzales, Maha Sanat Alreshidi, Nursid L Ibno, Shekah Salameh Alenzi
DOI:10.4103/sjhs.sjhs_100_20  
Introduction: The literature has consistently shown common results on the knowledge and attitude of nurses toward pain; there is a dearth in exploring minute details like the demographics that serve as the key to address the problem which this study aims at. Aims: This study aims to determine the knowledge and attitude of the staff nurses and whether a difference exists when their demographic profiles are considered. Methods: This study employed quantitative-comparative design. The researchers employed a self-report questionnaire to gather the data from the 262 staff nurses working at three big hospitals located in Hail City. The researchers used the simple random sampling method to obtain the number of participants needed. Mann–Whitney U-test and Kruskal–Wallis test were used to test a comparison between the level of knowledge on pain assessment of the respondents across their profile. Meanwhile, Kendall Tau was used to determine the difference between the levels of knowledge on pain assessment of the respondents as to their age, years of experience, and number of trainings. Results: The mean knowledge and attitude of nurses is 20.39. When the demographic profile was compared to the level of knowledge, only area/unit of assignment (0.01) and number of training (0.01) showed significant results. The number of training (0.01) yielded positive relationship concerning the difference between the level of knowledge and attitude of nurses. Conclusion: Staff nurses have a low level of knowledge and attitude regarding pain management. The area/unit of assignment has shown to influence the knowledge and attitude, while the number of trainings has a positive effect on the knowledge and attitude.
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Perception and assessment of psoriasis in the general population of Riyadh, Saudi Arabia p. 102
Seba Almutairi, Abdulaziz Alotaibi, Mohammad A Almohideb
DOI:10.4103/sjhs.sjhs_180_19  
Context: Psoriasis is a chronic skin condition with a prevalence ranging from 0.51% to 11.43% and 0% to 1.37% among adults and children, respectively. Its consequences can affect patients' quality of life. Aims: This study aims to assess the perception of psoriasis among general population at Riyadh, Saudi Arabia. Subjects and Methods: This is a cross-sectional study based on a structured interview questionnaire that was distributed among the residents of Riyadh. Inclusion criteria encompassed participants ≥18 years old, all educational levels, nationalities, and both genders living at Riyadh. The minimum sample size required was 385. The data were analyzed using SPSS version 23 with confidence interval of 95% and P ≤ 0.05 considered statistically significant. Results: This study included 101 (26.2%) men and 284 (73.8%) women. Seventy-eight percent of the participants were familiar with the term “psoriasis”' in Arabic. The majority of the participants had heard about the term from family and friends. Sixty-eight percent of the participants considered the disease to place a significant burden on affected individuals, 41% stated that there are effective drugs available for the treatment of psoriasis, and 12.2% considered the disease to be contagious. Some of participants did not want to shake hands, share their food, share the same swimming pool, and be in a relationship with psoriatic patients (18.2%, 13%, 54.1%, and 32%, respectively). Conclusions: Although most of Saudi population are familiar with the term “psoriasis” in Arabic, there is a significant lack of knowledge about psoriasis. This emphasizes on the need to increase psoriasis awareness, which may be achieved through campaigns, seminars, and the media to improve the knowledge and reduce the stigmatization of psoriasis.
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Cytopathological diagnosis of filariasis by fine-needle aspiration cytology in different body locations: A retrospective study of 5 years in central India p. 109
Abhay Vilas Deshmukh, Shubhangi Natthuji Mangam, Pravinkumar Vijaykumar Ghongade, Vitaladevuni Balasubramanyam Shivkumar
DOI:10.4103/sjhs.sjhs_63_20  
Background: Filariasis is one of the common health problems in tropical countries. The parasite causing the disease primarily resides in lymphatic channels or lymph nodes. It can remain viable in these places for decades. The clinical presentation may vary from superficial palpable swelling to pain and erythema. The cytopathological diagnosis of microfilaria on fine-needle aspiration cytology (FNAC) helps in prompt recognition of the disease. Aim: The aim of the study was to analyze the presence of microfilariae (MF) diagnosed on FNAC from different body locations based on clinicopathological data and cytopatholgical features. Methods: It was a retrospective observational study in which cases of MF over last 5 years which were diagnosed on FNAC were analyzed. Results: Of 34069 cases of FNAC and 45623 cases of fluid cytology, 27 cases (0.033%) of filariasis were diagnosed on cytopathology smears. The various sites included the skin and soft tissue (8 cases), lymph node (6 cases), breast (5 cases), pleural fluid (4 cases), scrotal swelling (3 cases), and thyroid gland (1 case). Eosinophilia was found in 18 cases (66.67%). The background showed inflammatory infiltrate in 17 cases (62.96%), while florid reactive mesothelial hyperplasia was seen in 2 cases (7.4%). We found 4 cases (14.81%) of incidental malignancies along with MF (3 breast and 1 pleural fluid). Conclusion: Although rare, filariasis should always be suspected as a differential diagnosis of FNAC in different body location swellings. A careful attitude while screening cytopathological smears helps to diagnose MF even in asymptomatic cases.
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In-homes' medicines storage, use, and beliefs: Saudi study p. 114
Ahmed Salah Eldalo, Mirghani A Yousif, Abrar A Alotaibi, Afnan A Alghamdi, Wejdan S Alzaidi
DOI:10.4103/sjhs.sjhs_172_19  
Background: In-home medication storage and use in Saudi Arabia seem to be common by consuming medicines that liberally dispensed in community pharmacies as well as freely taken without medical advice at homes level. Objective: The prime objective of this study was to investigate the prevalence of stored medicines especially antibiotics, the storage status of medicines in home and community general perception on medicines' storage and use at the level of Saudi homes. Methodology: A study was carried out in different areas in a Western Region, Saudi Arabia, using a pretested questionnaire on one thousands of randomly selected participants. Data were computed and analyzed using (IBM SPSS) Program (version 22). The association between variables was tested; P ≤ 0.05 was taken as a statistically significant cut measure. Results: The response rate was (97.6%). Females were dominant (82.8%). Almost (99.7%) of the investigated families had at least one drug product stored at homes, (66.1%) of the stored medicines were kept for future use and (19.7%) of participants used to take the medicines without any consultation. Penicillin and cephalosporin were the most commonly store antibiotics. The study revealed poor compliance (49.7%), half of the participants (50.5%) admitted they used to recommend medicines' use for treatment of the same symptoms to others, (16.1%) used to buy medicines that were suggested by friends and (33.46%) of participants stored antibiotics without prescription. Conclusion: In Saudi Arabia, there is still a great need to emphasize on rational use of drugs to safeguard population health and to avoid economic losses by relying on using medicines on professional advice.
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Knowledge and perceptions of antimicrobial stewardship program among health-care students in Saudi Arabia p. 122
Rina Tripathi, Ahmed A Albarraq, Hafiz A Makeen, Saad S Alqahtani, Pankaj Tripathi, Shyam Sunder Pancholi
DOI:10.4103/sjhs.sjhs_192_19  
Background: National antimicrobial stewardship program (AMS) is an initiative to prevent antibiotic misadventures. Currently, AMS is not compulsory as part of the undergraduate health-care students in Saudi Arabia. Identifying gaps in knowledge and a better understanding of their perceptions about AMS could assist in recommendations for appropriate changes to the curricula that may lead to more appropriate use of antimicrobials within the multidisciplinary team. Objective: The objective of this study was to assess the AMS knowledge and perceptions among health-care students – pharmacy, medicine, dental, nursing, and microbiology. Methods: A cross-sectional, descriptive survey was conducted among health-care students of different colleges of Jazan University, Saudi Arabia. Collected data were analyzed using SPSS version 23. Results: A questionnaire was supplied to 563 students and 390 (69.27%) responded. AMS was known to 71% of the participants, while 50.3% were familiar with AMS in Saudi Arabia, with a significant difference among students of different health-care colleges. The broad appreciation of AMS goals, team members, and role of pharmacist was more among dental, microbiology, and pharmacy students as against nursing and general medicine. All health-care students possess good knowledge about causes of antimicrobial resistance (AMR). Formal training on AMS was received by merely 48.97% of the participants. A clear majority (80.8%) opined that better understanding of antimicrobial use is important for career, and 79.0% registered a need of incorporating AMS training in curricula. Conclusions: Concepts of AMS need to be included in the undergraduate health-care curricula to promote the rational use of antimicrobials and minimize incidences of AMR to improve clinical outcomes.
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A retrospective study on snakebite and its outcome from a referral-cum-teaching hospital of Kolkata, India p. 130
Sisir Chakraborty, Prithwijit Banerjee, Rajdip Hazra, Somnath Maity, Swati Banerjee, Niladri Sarkar
DOI:10.4103/sjhs.sjhs_81_20  
Background: Snakebite-related fatality is among the highest in West Bengal and such patients display variety of clinical features. Precious time is also lost during the transport to health-care centers. Aim: The study was undertaken to find out the incidences and mortality associated with different snakebites and to compare the clinical features between the survivor and nonsurvivors. Materials and Methods: The data were derived from 286 indoor case records of snakebites from a referral hospital of Kolkata during January 2018 to September 2019. Patients' demographic details, exact bite history with subsequent management, clinical profile, and final outcome were compiled for analysis. Student's t-test and Fisher's exact test were performed to find out statistical significance. Results: The mean age of the patients was 28.44 ± 16.92 years and 69.23% were male. Overall, 67.13% of patients required hemodialysis and 13.63% ultimately died. Russell's viper caused the most number of bites (58.04%) and highest mortality (15.66%). Nonsurvivors had significantly higher levels of creatinine, urea, total count, total bilirubin, and prothrombin time and significantly low hemoglobin and platelet counts than that of the survivors. Bite-to-hospital time was also significantly prolonged among nonsurvivors (9.08 ± 9.68 h versus 4.64 ± 5.58 h; P = 0.0001). The highest (29.17%) mortality was observed among those who reported after 12 h of bite. Conclusion: Maximum snakebite-related mortalities were due to Russell's vipers in the current study. Patients with prolonged bite-to-hospital time were most vulnerable. Sepsis, coagulopathy, and acute kidney injury were significantly higher among the nonsurvivors.
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Knowledge of first aid management of epistaxis among medical interns attending King Fahad Armed Forces Hospital in Saudi Arabia p. 136
Ahmed Abu-Zaid, Mohammed Alomari, Asim M AlMazmomy, Majed Al-Hayani, Abdulrahman G Bazi, Hatem Althagafi, Housam Y Almadani
DOI:10.4103/sjhs.sjhs_68_20  
Aim: The aim of this study is to explore the knowledge of medical interns about first aid in the management of epistaxis. Materials and Methods: An anonymous, cross-sectional, and validated survey-based study was conducted in January 2020 at King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia. Results: A total of 57 medical interns responded to the survey. The vast majority of survey respondents were male (78.9%) and single (80.7%). Around 57.9% of the respondents declared that epistaxis is regarded as one of the emergency situations. A sum of 71.9% of medical interns correctly identified “finger nail trauma” as the most common cause of epistaxis. In addition, while 71.9% of medical interns correctly answered, “sitting with head tilted forward” as the proper management position for a patient with epistaxis, only 52.6% of medical interns correctly answered, “pinching the lower cartilaginous part of the nose” as the primary measure to stop epistaxis. When medical interns were asked about what to do if the patient continued to bleed from the nose in the emergency room after the primary measures had been done, only 50.9% of medical interns correctly answered with “refer the patient to an otolaryngologist to take further care.” Using two-tailed Chi-square test, there were no differences in the percentages of correct answers among the surveyed medical interns according to gender (P > 0.05). With regard to the sources of information about first aid in the management of epistaxis, the top selected source by medical interns was “self-taught” (52%), followed by “medical textbooks” (19%). Conclusion: The surveyed interns had unsatisfactory knowledge about epistaxis first aid. There is a pressing need to establish solid curricular, extracurricular, and institutional measures to increase the intern's awareness of first aid knowledge in the management of epistaxis.
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An exploration of barriers to patients' safety from the perspective of emergency nurses p. 141
Abdulellah Al Thobaity
DOI:10.4103/sjhs.sjhs_15_20  
Background: The roles of emergency nurses include providing high-quality health care to patients, ensuring their safety, and liaising with their families. Identifying barriers by nurses to achieving patients' safety in Saudi Arabia is vital as there is a lack of the evidence on the topic. Objective: The study aim was to identify major barriers to the provision of patients' safety by nurses in the emergency department. Methods: A cross-sectional study was conducted in the nursing departments of two hospitals in Taif City. Data were collected through questionnaires administered at both hospitals between September 20 and October 20, 2019. Purposive sampling was used to recruit participants from the emergency departments who attained a score of 33 after responding to the questionnaire items (Likert scale, 1–5). The data were entered into SPSS® Statistics version 24. Descriptive statistics, such as mean, frequency, and standard deviation were calculated. Principal component analysis was used, with varimax rotation, to ensure high validity and reliability. Results: Sixteen barriers were quantified, validated, and grouped by category: (1) poor competencies, (2) poor evaluation and reporting, and (3) poor management and leadership. The most significant barriers were staff shortages (mean of 4.16), the absence of feedback from leaders (mean of 3.63), and lack of information on safety goals for patients (mean of 3.47). Conclusion: It is necessary to improve nurses' competencies, perform regular evaluations, and enhance nursing leadership to enhance patients' safety. Education, leadership, and research are key tenets.
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Health literacy and attitudes of caregivers of intellectually disabled children towards eye care p. 146
Lina H Raffa, Mohammed R Algethami
DOI:10.4103/sjhs.sjhs_215_19  
Background: The development of visual impairment in young children can negatively impact visual, motor, and cognitive function, and subsequently, affect the child's psychosocial functioning. Objective: The objective of this study is to assess the eye care status among children with intellectual disabilities (IDs). Methodology: A questionnaire was designed to explore the attitudes of parents toward eye care for their intellectually disabled children aged 3–17 years and possible barriers to accessing eye care between April 2018 and April 2019. Results: A total of 198 completed questionnaires were analyzed (19.3% response rate). Sixty-four caregivers (32.3%) believed in the importance of eye examinations for children with ID. Although 72 participants (36.4%) believed their children had visual impairment, 95 (47.9%) reported that their children had never received an eye examination in their lifetime. Only 80 caregivers (40%) had sought ophthalmological care for their children within the last 24 months. Having had a previous eye examination was not significantly associated with any sociodemographic factors. Among the caregivers' major reasons for not seeking eye care was the belief that their children did not need an eye check-up (68.9%), followed by prioritizing other medical issues (11.7%), transportation barrier/financial burden (5.8%), and lack of social support (4.9%). Conclusion: The vision care status among students with ID in special needs schools in Jeddah is poor, highlighting the necessity of establishing routine vision screening check-ups coupled with multidisciplinary health assessments.
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Primary care physicians' knowledge, attitudes, and practices related to diabetic retinopathy in Buraidah city, Qassim region, Saudi Arabia p. 152
Abdulrahman Abdullah Alasqah, Faisal Ibrahim Aldosari, Abdullah Ibrahim Almutaz
DOI:10.4103/sjhs.sjhs_46_20  
Background: Diabetic retinopathy (DR) is one of the severe complications of diabetes that can result in complete blindness when it presents late in the course of the disease. The role of primary care physicians (PCPs) in the screening, prevention, and possibly referral of patients with this complication is of great importance. Materials and Methods: An analytic cross-sectional study was conducted in all primary care clinics in Buraidah city, Qassim region, Saudi Arabia. The sampling technique used is convenience sampling. The sample is PCPs (PCPs). Data were collected using a pretested, semi-structured questionnaire with sections for assessment of knowledge, attitudes, and practices toward DR in the PCPs. Results: Out of a total of 106 physicians, 100 have answered the questionnaire with a response rate of 94%, 75% have received postgraduate training. Eighty-seven percent of the PCPs have agreed that an ophthalmoscope is needed in their clinic while only (35%) have agreed that they can do an ophthalmoscopic examination confidently to detect DR in patients with diabetes. Around 23% have disagreed that diabetic patients can have DR despite having a good vision, and only 56% have agreed that pregnancy can actually worsen DR. Conclusions: The knowledge, attitudes, and practices of PCPs are sub-optimal. Dilated Fundus Examination using a slit-lamp ophthalmoscope is the best technique used in the screening of DR. Primary care centers should be equipped with more technologically advanced ophthalmic devices, and tele-screening should be utilized to precisely diagnose DR. Moreover, the communication with and referral to ophthalmology should be done on findings that are suggestive of DR. PCPs should stress the importance of screening to their diabetic patients. Finally, more efforts should be placed to increase knowledge in certain areas like DR effects in pregnant patients.
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CASE REPORTS Top

Intestinal strongyloidiasis in a patient of myasthenia gravis and diabetes mellitus p. 160
Prachala Rathod, Abha Sharma, Bibhabati Mishra, Archana Thakur, Poonam Loomba, Ashish Bajaj, Madhusmita Das
DOI:10.4103/sjhs.sjhs_225_19  
Strongyloidiasis is endemic in tropical and subtropical countries. It can become fatal and life-threatening in immunocompromised patients. We report a case of a 36-year-old female who was diagnosed with myasthenia gravis and type II diabetes mellitus. The patient complained of diarrhea with fever, vomiting, and dyspnea. On examination of stool in wet mount, 10–15 motile larvae/high-power field were seen. A methylene blue staining of fecal specimen was done to confirm the larvae as rhabditiform larvae of Strongyloides stercoralis. The patient was successfully treated with ivermectin. The authors recommend that in patients with myasthenia gravis, presenting with gastrointestinal manifestations, strongyloidiasis should be suspected, investigated, and treated accordingly.
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Successful management of acute respiratory distress syndrome in scrub typhus: A rare entity p. 164
Nishith Govil, Kumar Parag, Hariom Khandelwal, Bharat Bhushan Bhardwaj
DOI:10.4103/sjhs.sjhs_4_20  
Scrub typhus or tsutsugamushi disease is characterized by nonspecific signs and symptoms. Disease manifestation are acute fever, eschar formation at the site of chigger bite and serious respiratory complication. We report the case of a 22-year-old girl admitted in our intensive care unit (ICU) with the chief complaints of fever with chills, rigor, and severe headache diagnosed as scrub typhus. She was treated well for 7 days, cured, and discharged from the ICU. For a physician, awareness of regional prevalence and a history of travel to endemic areas or outdoor activities such as mountaineering and expedition should raise the suspicion for scrub typhus. Early diagnosis and treatment will prevent death and reduce morbidity.
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Tuberculous involvement of multiple flexor and extensor tendon sheaths of hand and wrist p. 167
Ashwani Jain, Ayushi Chhabra, Ankur Malhotra, Deepti Arora, Sarika Goel, Satish Pathak
DOI:10.4103/sjhs.sjhs_113_20  
Tuberculosis (TB) continues to be a major health burden in developing countries. It can be pulmonary or extrapulmonary, but involvement of tendon sheaths is extremely uncommon. Due to nonspecific clinical features and wide differentials, diagnosis is often delayed. Here, we report one such rare case, where a male patient presented with multiple, painless swellings over the wrist and hand and posed a diagnostic challenge on radiological investigations (ultrasonography and magnetic resonance imaging). The final diagnosis of TB tenosynovitis was confirmed only on histopathological examination. Tubercular tenosynovitis of hand is a rare entity, which mimics a variety of clinical conditions, often leading to delay in diagnosis and appropriate timely treatment. Thorough clinico-radiological and pathological examinations are thus necessary to diagnose this condition.
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Primary carcinosarcoma of the spleen – A rare tumor p. 172
Jayalakshmy Payippat Leelamma, Deepa Sujatha, Nila Theresa Davis
DOI:10.4103/sjhs.sjhs_68_19  
A 65-year-old woman with an acute abdomen underwent emergency laparotomy and excision of the spleen. Pathologic examination revealed a neoplasm in the spleen composed of an intimate admixture of malignant epithelial and stromal elements. In the absence of a neoplasm elsewhere, the final diagnosis rendered was primary splenic carcinosarcoma. This article describes the gross and histopathological features of this rare splenic tumor in a 65-year-old female and discusses the possible origin and pathogenesis. The surgery is the mainstay of treatment and prognosis is dismal. Given the rarity of this tumor in the spleen, reporting this case will add to the scarce data currently available.
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LETTER TO EDITOR Top

Comments on the “Effectiveness of team-based learning with high fidelity simulation in an undergraduate pediatric course for nurses” p. 175
Faizan Zaffar Kashoo, Mehrunnisha Ahmad
DOI:10.4103/sjhs.sjhs_49_20  
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